Provider Demographics
NPI:1619424330
Name:SANDERS, KISHINA SHONTRELL (FNP-C)
Entity Type:Individual
Prefix:
First Name:KISHINA
Middle Name:SHONTRELL
Last Name:SANDERS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 WOODDELL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-4043
Mailing Address - Country:US
Mailing Address - Phone:601-201-1971
Mailing Address - Fax:
Practice Address - Street 1:768 AVERY BLVD N
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5219
Practice Address - Country:US
Practice Address - Phone:601-487-6482
Practice Address - Fax:601-487-6528
Is Sole Proprietor?:No
Enumeration Date:2016-09-10
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901734363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily